Preop Assessment

Preoperative The following preoperative interventions are definitely beneficial: Smoking cessation for eight weeks Inhaled ipratropium or tiotropium for all patients with clinically significant COPD Inhaled beta-agonists for patients with COPD or asthma who have wheezes or dyspnea Preoperative glucocorticoids for patients with COPD or asthma who are not optimized and whose airway obstruction has not been maximally reduced Delay elective surgery if respiratory infection present Antibiotics for patients with infected sputum Preoperative inspiratory muscle training Intraoperative The following intraoperative interventions are definitely beneficial: Choose alternative procedure lasting less than three to four hours when possible Minimize duration of anesthesia Surgery other than upper abdominal or thoracic when possible Regional anesthesia (nerve block) in very high-risk patients Avoid use of pancuronium as a muscle relaxant in high-risk patients Choosing laparoscopic rather than open abdominal surgery when possible may be beneficial. Epidural or spinal anesthesia may confer lower risk than general anesthesia, though this remains an area of debate. Perioperative pulmonary artery catheterization is not beneficial. Postoperative The following postoperative interventions are definitely beneficial: Deep breathing exercises or incentive spirometry in high risk patients Epidural analgesia in place of parenteral opioids Continuous positive airway pressure (CPAP), intercostal nerve blocks, and selective use of nasogastric tubes (for symptoms only) after abdominal surgery are probably beneficial postoperative interventions.

SUMMARY AND RECOMMENDATIONS The process of estimating and reducing the risk of perioperative cardiac events (eg, cardiac death and nonfatal MI), includes the following four components: Defining the urgency of surgery, which may supersede risk stratification. Initial risk assessment. Refinement of initial risk assessment with noninvasive testing in selected patients. Consideration of therapies that may reduce risk in high-risk patients (eg, revascularization, beta blockers, and statins). Initial risk assessment The initial risk assessment consists of three steps. Does the patient have a high risk condition that is considered a major predictor of risk in the 2007 ACC/AHA guidelines (eg, unstable angina or recent MI [within 7 to 30 days], decompensated heart failure, severe heart valve disease) [81]? Such patients require intensive management and often a delay in or cancellation of surgery. What is the surgery-specific risk of the planned operation? What is the patient-specific risk? This can be estimated using the revised cardiac risk index (RCRI) (table 2). The indications for noninvasive stress testing in asymptomatic patients are estimated high risk (3 RCRI criteria) or intermediate risk (1 to 2 RCRI criteria) plus poor or indeterminate functional status, a history consistent with coronary disease, or high-risk surgery. Patients requiring emergency surgery typically do not undergo stress testing. In addition, the patient's long-term cardiac prognosis independent of surgery should be taken into account when deciding to proceed with surgery or to perform preoperative coronary revascularization. In addition, patients should be assessed at the time of the preoperative evaluation for the need for long term beta blocker use. In these patients, we recommend the initiation of beta blockers days, and preferably weeks before surgery. For those patients who cannot receive them in this time frame, we advise against their initiation hours before surgery. Angiography and revascularization Cardiac catheterization and angiography should be performed in patients with high risk features on noninvasive testing (eg, reversible large anterior wall defect, multiple reversible defects, ischemia occurring at a low heart rate, extensive stress-induced wall motion abnormalities, transient ischemic dilatation).

 Among patients in whom preoperative coronary angiography is performed, we recommend revascularization only in patients who have high-risk features that fulfill current criteria applicable to all patients with coronary disease . In patients without such indications, the CARP trial and DECREASE-V Pilot Study found no improvement in outcomes with revascularization compared to medical therapy. We recommend that elective noncardiac surgery be postponed until after myocardial revascularization has been performed. Because of the risk of stent thrombosis, which can be a catastrophic complication, we recommend NOT performing PCI with stenting if surgery cannot be reasonably delayed beyond the minimum recommended duration of combined antiplatelet therapy (one month for bare metal stents and twelve months for drug-eluting stents according to labeling instructions). Such patients can be treated with angioplasty alone, waiting at least one week before performing noncardiac surgery to permit healing of vessel injury at the balloon treatment site. Beta blockers Beta blockers are recommended for many patients with known coronary artery disease or myocardial ischemia by stress testing, unless there are contraindications. In patients scheduled for vascular surgery who have stable CAD, documented myocardial ischemia, or high cardiac risk (RCRI 3) (table 2), we suggest initiating perioperative beta blockade (Grade 2C). If beta blocker therapy is prescribed, the drug should be started at least 30 days before surgery and the dose should be titrated. In addition the patient should have close pre- and perioperative monitoring of heart rate and blood pressure to assure that the beta blocker is tolerated. Although there is a reduction in the rate of perioperative myocardial infarction, and possible a reduction in mortality in these patients, there is a concern about in increased rate of stroke. These issues should be discussed with the patient. Physicians and patients may reasonably choose to defer adding beta blocker therapy in such patients if they feel the risks outweigh the benefits. Examples include patients scheduled for lower risk vascular surgery (carotid endarterectomy) or those with a history of cerebrovascular accident for whom perioperative hypotension might be particularly concerning. We suggest continuing perioperative beta blockade in patients already being treated with beta blockers (Grade 2B). In patients at high cardiac risk (RCRI 3) scheduled for intermediate risk surgery, there is insufficient evidence upon which a recommendation can be made. The

benefits and risks of the preoperative initiation of beta blockers in this setting should be discussed in detail with the patient. Statins Among patients undergoing elective major vascular surgery, we recommend continuing statin therapy in patients already being treated and, in previously untreated patients, initiating statin therapy as soon as possible before elective vascular surgery (Grade 1A). (See 'Statins' above.) For patients on statin therapy undergoing urgent or emergent major vascular surgery, we recommend continuing such therapy (Grade 1B). For patients not on statin therapy undergoing urgent or emergent major vascular surgery, we suggest initiating therapy before surgery, if possible ( Grade 2C). Over the long-term, we recommend that statin therapy be titrated to recommended goals (Grade 1A).